Provider Demographics
NPI:1013190289
Name:EDUARDO VILLA, M.D., S.C.
Entity Type:Organization
Organization Name:EDUARDO VILLA, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-520-4887
Mailing Address - Street 1:5471 RFD
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8211
Mailing Address - Country:US
Mailing Address - Phone:847-520-4887
Mailing Address - Fax:847-520-4936
Practice Address - Street 1:622 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60070-2353
Practice Address - Country:US
Practice Address - Phone:847-520-4887
Practice Address - Fax:847-520-4936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36074074207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNA643303Medicaid
ILE75512Medicare UPIN
IL943550Medicare PIN